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Ana Isabel Maia de OliveiraIvonete Batista de Araújo
erros de Prescrição em Uma Unidade de tratamento
erros de Prescrição em Uma Unidade de tratamento
resUmoObjetivos: Avaliar o índice de erros de prescrição nas prescrições médicas dos pacientes admitidos em
uma unidade de terapia intensiva (UTI), o grupo de medicamentos mais relacionados aos erros de prescrição
e o índice de aceitação das sugestões farmacêuticas.Métodos: as prescrições médicas dos pacientes admitidos na UTI de um hospital universitário foram
analisadas. Os parâmetros considerados foram dose, intervalo de administração, via de administração,
velocidade de infusão e diluição dos medicamentos. Os medicamentos mais relacionados aos erros de
prescrição também foram avaliados, assim como a aceitação das sugestões farmacêuticas.Resultados: 741 prescrições foram analisadas e 480 (64,78%) foram incluídas no estudo. 374 erros de
prescrição foram encontrados após a análise da prescrição de 5007 medicamentos, o que resultou num índice
de erro de 7,47%. 41,67% das prescrições médicas continham pelos menos um erro e o erro no intervalo de
administração foi o mais comum (35,56% do total de erros). Os antimicrobianos foram os medicamentos
mais relacionados aos erros de prescrição. O farmacêutico realizou 152 sugestões de modificação das
prescrições, das quais 98,03% foram aceitas pelos médicos prescritores.Conclusão: os erros de prescrição são eventos comuns na UTI estudada, trazendo um risco em potencial
para os pacientes. O erro no intervalo de administração foi o tipo de erro mais freqüente nesse estudo. Os
antimicrobianos foram os medicamentos mais relacionados aos erros. A aceitação às sugestões foi elevada.Descritores: Erros de Medicação, Terapia Intensiva, Atenção Farmacêutica.
abstractPurpose: To evaluate the rate of prescribing errors in the prescribing orders of patients admitted to
an intensive care unit (ICU), the medication groups more related to the prescribing errors and the rate of
acceptance of pharmacist intervention.Methods: The prescriptions charts of patients admitted to the ICU of a teaching hospital in Brazil were
analyzed. The considered parameters were dose, dosing interval, route of administration, infusion time and
dilution of medications. The most common medications related to the errors were also evaluated, as well the
acceptance of the interventions made by the pharmacist.
Results: A total of 741 prescriptions charts were analyzed and 480 (64.78%) were included in the study.
374 prescription errors were found after the analysis of 5007 medication orders, which resulted in a error rate
of 7.47%. 41.67% of the prescriptions charts had at least one error and the dosing interval error was the most
common (35.56% of the errors). The antibiotics were the medications more related to the prescribing errors.
The pharmacist made 152 interventions and 98.03% of these were accepted by the physicians.
Conclusion: The prescribing errors are common occurrences in the studied ICU, bringing potential risk to the
patients. The dosing interval error was the most frequent type of error found in the study. The systemic antibiotics
were the medication group more related to the errors. The acceptance of pharmacist intervention was high.Keywords: Medication errors, Intensive care, Pharmaceutical care.
resÚmenObjetivos: Evaluar el índice de errores en la prescripción de medicamentos en las recetas de pacientes
ingresados en una unidad de cuidados intensivos (UCI), evaluar el grupo de medicamentos más relacionados
a los errores de prescripción y el índice de aceptación de las sugerencias realizadas por el profesional
Metodología: Se analizaron las prescripciones de los ingresados a la UCI de un hospital universitario. Los
parámetros considerados fueron: la dosis, el intervalo de administración, la vía de administración, la velocidad de
infusión y la dilución de los medicamentos. También se evaluó cuales son los medicamentos más relacionados a
los errores de prescripción y la aceptación de las sugerencias farmacéuticas realizadas al prescriptor.
Rev Bras Farm Hosp Serv Saúde. São Paulo v.3 n.3 6-10 jul./set. 2012
Resultados: 741 prescripciones fueran analizadas y un total de 480 (64,78%) fueran incluidas en el estudio. Tras analizar la prescripción de 5007 medicamentos,
se encontraron 374 errores de prescripción, por ende el índice de error en la prescripción fue de 7,47%. Un 41,67% de las prescripciones contenían por lo menos un
error. El error más recurrente se observó en el intervalo de administración (35,56%). Los antimicrobianos fueron los medicamentos más relacionados a los errores
de prescripción. El farmacéutico realizó 152 sugerencias de modificación en las prescripciones, de las cuales un 98,03% fueron aceptadas por los prescriptores.Conclusión: Los errores de prescripción son eventos recurrentes en la UCI estudiada, lo que representa un riesgo potencial en los pacientes
hospitalizados en ella. El error en el intervalo de administración fue el error más frecuente en este estudio. Los antimicrobianos fueron los fármacos más
relacionados a errores de prescripción. La aceptación de las sugerencias fue elevada.Descriptores: Errores de Medicación, Cuidados Intensivos, Atención Farmacéutica.
the literature, in an inappropriate dose for patients with renal or hepatic
failure or the lack of the dose in a prescribing order.
The medication process includes, at least, the prescription, the
Dosing Interval Error: the prescription of a medication in a dosing
dispensation and the administration of a medication. It is, therefore,
interval not reported in the literature, in an inappropriate dosing interval
a complex and multidisciplinary activity that involves physicians,
for patients with renal or hepatic failure or the lack of the dosing interval
pharmacists, nurses and other healthcare professionals(1-2).
Medication errors, defined as a failure in the treatment process that
Route of administration error: the prescription of a medication
leads to, or has the potential to lead to, harm to the patient, are common
in a route of administration not recommended by the literature, the
occurrences in the medication process, affecting especially inpatients(3).
prescription of a medication in an unsafe route or the lack of the route of
These errors affect between 4% and 17% of inpatients and are considered
administration in a prescribing order.
the major cause of harm to this population. They bring important clinical
Infusion time error: the prescription of a medication in an infusion
and economic implications, endangering patient safety and raising
time not reported in the literature or the lack of the infusion time in a
prescribing order for medications that induce toxicity or therapeutic
The ICU is the site of most medication errors in the hospital
response according to this parameter.
environment, which can be due the severity of illness of its patients, the
Dilution error: the prescription of an inappropriate dilution for an
prescription of a great number of medications and the stressful work
injectable medication or the lack of the dilution in the prescribing order
environment(5). The consequences of the errors are also more serious
in critical care patients. Nearly 19% of medication errors in ICU are life-
Each error rate was calculated using the following equation:
threatening and 42% create the need for additional treatment(6).
Rate of a type of error = (number of errors per type / total number
The pharmacist participation in the ICU is one of the strategies that
can be adopted to prevent medication errors, as this healthcare professional
Medication groups more related to errors. The analyzed medications
provides important information that makes the medication use safer(7-8).
were divided in groups according the Anatomical Therapeutic Chemical
The main objective of this study was to evaluate the rate of prescribing
(ATC) classification. This allowed the identification of medication
errors in the prescribing orders of patients admitted to an ICU, the
groups more related to the errors. The error rate per medication group
medication groups more related to the prescribing errors and the rate of
was calculated using the following equation:
acceptance of pharmacist interventions.
Rate of error per medication group = (number of group errors / total
Acceptance to pharmacist intervention. The pharmacist made
interventions on the errors found from 7:00 am to 5:00 pm. The
Study design. Cross-sectional, quantitative, descriptive and
interventions that resulted in the immediate change of the prescribing
prospective study that was carried out in the ICU of a brazilian teaching
order were considered accepted. The rate of acceptance was calculated
hospital. The referred ICU has 12 beds and receives patients from clinical
Rate of acceptance = (number of accepted interventions / total
Ethical considerations. The study was authorized by the ethics committee
of the university that manages the hospital. For each patient, a close relative
signed an informed consent after explanations about procedures and
importance of the research. Only the prescription charts of patients whose
relative signed the informed consent were included in the study.
A total of 741 prescriptions charts were analyzed and 480 (64.78%),
Data collection and statistical analysis. The data was collected
corresponding 5007 prescribing orders, were included in the study, as
during 92 days (May 15th to August 15th) from the 7:00 am to 5:00 pm.
they fulfill the inclusion criteria. At least one prescribing error was found
During this period, each prescribing order was analyzed and the data
in 41.67% (200/480) of the prescription charts. Table 1 shows the rates
was registered. The medications prescribed out of the daily period of
of the number of errors per prescription.
collection were evaluated on the next day. The Microsoft Excel 2007 was
used to calculate the rate of error.
Table 1 - Total Number and Rates of Errors per Prescription
Inclusion criteria. The prescription charts of patients which a close
relative signed the informed consent.
Number of Errorsper Prescription Number of Prescriptions
Exclusion criteria. The prescription charts of patients which a close
relative did not sign the informed consent were not included. The
electrolyte solutions and insulins, as well as, the dermatologic and inhaled
medications were also not included in the study.
Parameters and errors. The analyzed parameters on the prescribing
orders were dose, dosing interval, route of administration, infusion
time and dilution of medications. Any difference between the
prescription orders and the literature of reference (MICROMEDEX®,(9)
UptoDate®,(10)“Handbook of Injectable Drugs”)(11)was considered an
error. The following types of error were evaluated:
Dose error: the prescription of a medication in a dose not reported in
Rev Bras Farm Hosp Serv Saúde. São Paulo v.3 n.3 6-10 jul./set. 2012
The prescribing error rate was 7.47% (374/5007). The dosing interval
A total of 68 medications were related to prescribing errors and they
error had a rate of 35.56% (133/374), while route of administration
were divided according to the main ATC group. The error distribution by
errors corresponded to 26.74% (100/374) of total number of errors. The
main ATC group can be seen in Table 2, while Table 3 shows the most
dose errors, dilution errors and infusion time errors had a rate of 12.57%,
common medications in each ATC group.
Table 2- Error Distribution by Main ATC Group
Alimentary Tract and Metabolism (Group A)
Genito Urinary System and Sex Hormones (Group G)
Systemic Hormonal Preparations, Excl. Sex Hormones and Insulins (Group H)
Antiinfectives for Systemic Use (Group J)
Antiparasitic Products, Inseticides and Repellents (Group P)
Table 3 - Medications More Related to Prescribing Errors in Each ATC Group
Alimentary Tract and Metabolism (Group A)
Systemic Hormonal Preparations, Excl. Sex
*Rates corresponding to the total number of errors (374).The pharmacist made interventions in 152 prescribing orders, which
study developed in an important hospital in Brazil found an error rate of
corresponds to 40.64% (152/374) of the total number of prescribing
9.2%(18). The methodological differences make the comparisons to the
errors. The rate of acceptance to pharmacist intervention was 98.03%, as
only three interventions were not accepted.
At least one prescribing error was found in 41.67% (200/480) of
the prescription charts analyzed in the present study. This finding can
be related to the presence of residents in the ICU. In fact, other studies
The comparison between medication errors studies is a difficult
showed that these professionals commit more prescribing errors,
task, as definitions and methodologies used are widely variable. Thus,
especially at the start of the rotations(19).
comparison between different institutions can be misinterpreted by
The dosing interval error was the most common type of error,
confounding variables, as the individual prescribing practices(12-13).
corresponding to 35.56% (133/374) of the total number of errors. The
Although comparison difficulties, the rate of prescribing errors found
ICU that hosted this study receives a great number of patients with
in this study (7.47%) is similar to the findings of other studies, including
renal dysfunction, which requires the adjustment of the dosing interval
the systematic review of Lewis et al., which reported an error rate of
of many medications. However, this procedure was not taken in a great
7%(14-15). Of note, in these studies, the analyzed prescribing orders were
number of prescribing orders and the parameter was adjusted only after
handwritten by the physicians, while the orders analyzed on this study
were made using an electronic prescribing system. Regarding to this type
The route of administration error represented 26.74% (100/374) of
of prescribing system, the study of Shawahna et al.(16)found an error rate
total number of errors and was the second most common. A great part of
of 8.2% after the introduction of this technological support.
these occurrences was related to the prescription of medications by oral
The studies about medication errors in Brazil are still scarce(17).
route, while the patient was using a nasoenteral tubes for administration
However, the study of Bohomol, Ramos and D’Innocenzo identified 305
of medications and enteral nutrition.
medication errors in an ICU, of which 4.6% were prescribing errors. A
The dosing error was the third more common type of error found
Rev Bras Farm Hosp Serv Saúde. São Paulo v.3 n.3 6-10 jul./set. 2012
in the study, corresponding to 12.57% (47/374). This finding differs
patients. The dosing interval error was the most frequent type of error
from the data found in the literature, which points to this error as the
found in the study. The systemic antibiotics were the medication group
most common type of prescribing error(13, 16, 20). Most of these errors were
more related to the errors. The acceptance of pharmacist intervention
related to the prescription of conventional doses for patients of renal
was high and the integration of this healthcare professional in the ICU
multidisciplinary team can decrease the frequency of the prescribing
The dilution errors represented 12.03% (45/374) of errors. An
errors and, therefore, increase the patient safety.
important example of this type of error was the lack of this parameter on
the prescribing orders of some antibiotics, such as amikacin, clindamycin
and trimethoprim/sulfamethoxazole (co-trimoxazole). It is known
that these medications can produce important adverse reactions if
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The infusion time error corresponded to 13.10% (49/374) of
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(123/374) of total number of errors. This finding is also shown in other
studies, including those in ICU(13, 23). The meropenem and the cefepime
were the medications of the group with more prescribing errors, 9.36%
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Although the prescribing orders are made in the electronic system,
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